In the lab department of Denver Health Medical Center is a conference room so covered in sticky notes that they could probably hold up the wall, should it come to that.

The colorful rows of scribbled-on squares represent system glitches or flow problems or things that just don’t work right. Each also represents a chance to improve.

The notes are the product of a deployment of teams of employees, who fanned out across Denver Health, accosting anyone and everyone who works in the lab or whose work crosses paths with the lab. They asked:

“What are the things that keep you from working efficiently?” And “Are there things you see happening to patients that shouldn’t?”

Those questions are the essence of a multilayered efficiency system known as Lean that has swept through Denver Health over the past five years with the fervor of a religious conversion.

In an era marked by soaring health care costs and epidemic layoffs, even as it serves more and more uninsured patients while public funding dwindles, Denver Health has saved money and jobs — and improved patient care — using decades-old Toyota practices.

$54 million benefit

Since its Lean conversion in 2005, the city’s public health system has benefited to the tune of $54 million in increased revenue, money not spent and expenses cut, according to chief financial officer Peg Burnette.

Without those savings, Denver Health would “absolutely” have had to cut jobs, said its chief executive, Dr. Patricia Gabow.

At its essence, Lean is supposed to cut costs and make work consistent and consistently high-quality, said Phil Goodman, a longtime employee who has become Denver Health’s in-house Lean guru.

The system, which blossomed at Toyota as the Japanese rebuilt their economy after World War II, has long been a manufacturing darling.

Now, Lean is spreading to health care systems throughout the country.

The Children’s Hospital of Wisconsin, Intermountain Health Care in Salt Lake City and Virginia Mason Medical Center in Seattle, among others, are Lean acolytes.

“They know they’ve got to cut costs,” said Dr. James Levett, a cardiac surgeon and past chairman of the American Society for Quality’s health care division.

“In general, I would say we believe there is probably 20 percent to 40 percent waste in health care,” he said. “And if you want to get rid of waste, that’s the key focus of Lean.”

Waste that has been confronted and reduced at Denver Health in the past five years includes unnecessary multiple prescriptions for asthma inhalers. Launching a centralized process for ordering the inhalers is expected to save $166,348 over a year.

In the lab, consolidation and rearranging work stations and equipment so that work flow is more convenient — a big Lean tenet — has saved $88,000 and decreased turnaround times for test results by 25 percent, on average, said department manager Linda Kaufman.

Setting priorities improved emergency care

Every day, about 350 patients, on average, show up in Denver Health’s emergency room. If they’re not having a heart attack or bleeding from a gunshot wound, they tell a nurse their name and age and what’s wrong.

Then they wait.

On average, they wait more than two hours, although about 5 percent of those noncritical patients give up before they see a doctor.

To change that, a team of a half-dozen or so hospital employees spent a week talking to patients, nurses, doctors and clerks, and watching.

At the end of that week, members of the group — known as a “rapid-improvement team” — described what they found, and what they proposed to do about it, to a roomful of colleagues and their boss, Dr. Patricia Gabow, the hospital’s chief executive.

What they found was that the hospital does a good job of directing patients with non emergency medical problems such as stomachaches and sore throats to its Adult Urgent Care clinic.

The few with heart attacks or gunshot wounds are treated immediately.

It’s those with emergencies that are not life-threatening — the guy who sliced his thumb instead of the turkey, the woman who slipped on ice — who wait.

For them, Dr. Christopher Colwell, associate director of the emergency department and rapid-improvement team member, proposed creating a third path, a sort of nonemergent emergency track.

The group tried it during the July Rapid Improvement Event, and the result was, well, rapid improvement.

“With this fast-tracking, we saw five or six patients per hour,” Colwell said, compared with an average of two patients per hour normally.

At the event’s culminating meeting, Gabow listened, asked a couple of questions, then pronounced the experiment “courageous.”

The following week, Colwell said there are kinks to be worked out — how to staff that third track being the main one.

Still, he predicted a faster emergency room would be up and running by year’s end.

In 2006, all the managers in all the engineering fiefdoms were ordered to haul their treasure to a central location — deep beneath the engineering department’s headquarters.

There, Annette Marquez sorted it. It took six months, but she labeled it all, organized it and placed it in color-coded bins: red for electrical, yellow for mechanical and carpentry, blue for plumbing, etc. And she arranged it all so pleasantly, the whole scene would’ve made Martha Stewart tear up.

Now, Marquez is the queen of building and maintenance stuff, the lone employee responsible for cataloguing it, accounting for it and ordering replacements. Orders go through her, so there is less duplication or hoarding of parts and fewer managers falling for, as she put it, a sales pitch delivered in a skirt.

Being able to find things saves time for employees. Having centralized ordering of parts and equipment saves money. In 2009, the engineering department spent $613,651 less on repair and maintenance and supplies than in the pre- Lean high year of 2005.

Hospitals around the country want to know how Denver Health did it, Gabow said.

“It really grew out of my being old,” said Gabow, 66.

Changing the old ways

While technologies and treatments have made enormous strides during her career, nuts- and-bolts hospital operations haven’t, she said.

“We were doing many things exactly the same as we did when I was an intern 40 years ago,” she said.

That’s changing.

A day after making the rounds and talking to employees, that lab team’s members took turns revealing what they had found.

They’ve made a lot of improvements in the department, but apparently there is still work to be done.

One of the first observations brought up over that conference-room table was that doctors order tests they don’t really need.

“Do the same physicians do it over and over?” asked Scott Brubaker.

In most settings, Brubaker would be called a consultant or facilitator, but in Lean lingo, he is a “sensei.” For 19 months, he has been commuting from Florida to help guide Denver Health on its path to efficiency.

Levett said one of the reasons Lean is so often successful is that it’s not management telling the staff how to improve — it’s the other way around.

Still, meetings such as the lab gathering are almost guaranteed to produce finger-pointing and defensiveness.

That’s where Brubaker steps in, reminding participants of Lean precepts. When someone said a particular function works better under a particular employee, he pounced.

“That’s personal, that’s not process, and that’s not acceptable,” he said. “That means there is no standard of work.”

Despite seven employees — not including Brubaker, who is a contractor — devoted full time to Lean, Gabow said the program’s cost is minimal.

Levett said the average initial investment to get Lean running is around $25,000.

While layoffs seem to have become the most convenient cost-cutting strategy rather than a last resort, Lean is an antidote to that approach.

Last year, Denver Health provided but didn’t get paid for $360 million in medical care. That’s up from $270 million in 2005. At the same time, government aid for the public hospital dropped by $18 million, chief financial officer Burnette said.

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